Patient self management of oral anticoagulation and patient self testing of INR -
Anticoagulation with vitamin K antagonists (for example, warfarin) reduces thromboembolic complications in patients with common chronic conditions, including atrial fibrillation, history of deep venous thrombosis and pulmonary embolism, and mechanical heart valves . In the United States, more than 5% of persons aged 65 to 74 years and more than 10% of persons aged 75 years or older receive long-term oral anticoagulants. In 2007, the cost of this medication alone was $905 million in USA. As the population ages, use and costs are likely to increase substantially. We find it very difficult to take care of the less educated people who are on oral anticoagulant medications. Many times the hospitals are not able to provide this care after major interventions and operations. Vitamin K antagonists have a narrow therapeutic window, and patients require frequent laboratory monitoring to ensure that they are neither excessively anticoagulated, which increases the risk for a bleeding event, or underanticoagulated, which increases the risk for thromboembolism. Recent trials have shown that direct thrombin inhibitors, which do not require intensive monitoring, may be as efficacious as vitamin K antagonists. We hope the new drugs will this simpler and safer until then we need to keep service active for the patients who are on oral anticoagulants for prevent of recurrent thrombotic complications. The review of these patients on oral anticoagulants indicated that compared with usual clinic care, Patient Self Testing with or without Patient Self Management is associated with significantly fewer deaths and thromboembolic events, without any increase in bleeding complications, for a selected group of motivated patients requiring long-term anticoagulation with vitamin K antagonists.
Ref : Annals of Inernal Medicine , April 5, 2011, 154 (7)

Carotidobrachial bypass in a Takayasu's disease patient - 7yrs follow up.

The surgical treatment of Takayasu's disease is complicated due to many reasons. It has been complicated by the extensive nature of the lesions, lack of accurate knowledge regarding the preferred sites and extent of the lesions, presence of skip lesions, and chances of reactivation. These patients are usually young, with an otherwise normal vascular system beyond the diseased area. Previously published reports expressing reservations about the efficacy of surgical treatment do not seem justified. Careful assessment of each patient as to his residual disability after conservative treatment and the haemodynamic status will make surgical treatment safe and rewarding for a large number of patients. Immunological investigations indicate the possibility of a mechanism  involving immune complex formation on a background of defective T-lymphocyte function in Takayasu's disease. Whereas the original antigenic trigger could be any one of a number of different possibilities, parasitic infestation and chronic infection in the intestines along with protein energy malnutrition may be possible etiological factors. The figure shows the patent right carotid brachial bypass with saphenous vein graft after 7 years, and she developed occlusive disease in the left subclavian artery in the recent past with symptoms of claudication in the left arm.